Joyce Eisenberg Keefer Medical Center D/P SNF

In the surveyor’s words

From the most serious findings on record at Joyce Eisenberg Keefer Medical Center D/P SNF, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 26, 2021

  Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from abuse, after a certified nurse assistant (CNA 1) kicked Resident 1 in the shin and attempted to punch him in the face. This failure had the potential to cause Resident 1 mental distress and anxiety due to the abuse. This failure resulted in a small purple discoloration to Resident 1's left shin. Findings: A review of Resident 1's Face Sheet (admission record), dated 9/29/20, indicated the facility admitted Resident 1 to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880Sep 28, 2021

  On 09/28/2021, at 11:59a.m., during an interview with the Supervisor of Food Services, she (Supervisor of Food Services) stated all staff in the kitchen are required to get COVID-19 questionnaire screening and temperature checked prior to starting their shift. The Supervisor of Food Services also stated the supervisor will check temperature and keep a log of the screening for all the kitchen staff. On 09/28/2021, at 12:10p.m., during a record review of the Staff Screening Log - Dietary Department 9/26/2021 to 10/02/2021, it indicated only the temperature of the staff and no COVID-19 symptoms checks were marked. […]

• No harm, potential for more than minimal, patternF577Mar 12, 2026

  Based on observation, interview, and record review, the facility failed to notify residents of the existence and the location of the results of the most recent standard survey (means the Statement of Deficiencies Form CMS-2567) for ten (Resident 189, Resident 30, Resident 51, Resident 59, Resident 62, Resident 65, Resident 83, Resident 203, Resident 219, and Resident 236) of 11 sampled residents in the resident council. This deficient practice had the potential for residents and their representative to not know how the facility is performing regarding resident care. Findings: a. […]

• No harm, potential for more than minimal, patternF605Mar 12, 2026

  Based on interview and record review, the facility failed to ensure adequate monitoring of resident's orthostatic blood pressure (taking blood pressure measurements when lying, sitting, and standing to detect for significant drop in blood pressure during each position change) when taking a prescribed antipsychotic medication for one out of five residents (Resident 81) reviewed under unnecessary medications. This failure had the potential to result in Resident 81 receiving inappropriate dosage of an antipsychotic medication and experiencing symptoms of orthostatic hypotension (a significant drop in blood pressure with position change), which could lead to serious complications such as fainting and falls. […]

• No harm, potential for more than minimal, patternF656Mar 12, 2026

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document outlining a detailed approach to care customized to an individual resident's need) for: 1.One of two sampled residents (Resident 1) with a moisture associated damage (MASD) investigated during review of pressure ulcer/pressure injury (PU/PI - injury to the skin and underlying tissue resulting from prolonged pressure on the skin). 2. One of two sampled residents (Resident 180) whose care plan did not include all interventions agreed upon by the interdisciplinary team (IDT - a collaborative group of health care team members from different specialties who work together to address all aspects of resident's well-being) investigated for falls. […]